Care Coordination: Enabling Population Health

Posted: February 1, 2023 | Category: News

By Nina Taggart, MD, MA, MD, MBA, FAAO, Senior Medical Director of Accountable Care, Valley Preferred

With health care already distributed across multiple settings and providers, managing health is often overwhelming for the nearly 30 percent of Americans with multiple chronic conditions. (1) Population health-based care delivery is one approach to supporting these patients. Care coordination brings that model to the personal level through individualized care plans and interventions producing high quality, high-value health care. (2) The goal is to achieve safer and more effective care through better care activity coordination.

Expanding care beyond the physician

At its core, care coordination in the primary care practice enables information sharing among all the providers involved with a patient’s care. Each member of the care coordination team works to identify the patient’s needs and preferences and communicate them at the right time to the right people, so that information is used to provide safe, appropriate, and effective care to the patient. And everyone works together toward the same end.

In this population health model, providers are paid for maintaining and improving the health of their patient panels. Population health initiatives’ clinical and financial results strongly rely on preventing illness progression while continuing to care for patients when illness strikes, therefore, an integrated effort is essential. “Expanding the care team has become more critical than ever before,” says Jonathan Burke, DO, CHCQM, Medical Director, Clinical Services with a population health management and data analytics firm. “Physicians can’t do it alone and should not be expected to. We all know it takes a village to care for one patient, so a team-based approach is essential.”

The “team” typically includes physicians, Advanced Practice Clinicians (APCs), social workers, nurse case managers, and pharmacists who are available to support a patient’s plan of care. To understand how the process flows, we’ll look at how data sharpens the focus of care coordination, what the team members do, and some results of this work

Acting on data

Actionable information about the population under management drives care coordination interventions. In addition to sharing EMR information, these teams rely on data extracted from payers and electronic health records to develop registries that proactively identify patients most in need of care coordination services. They are often patients that have not been to a doctor’s office in quite some time! Using integrated claims and clinical data provides a more complete picture of a panel that shows what is, and isn’t, happening away from the practice. That helps direct these valuable resources for the greatest impact supplementing the standard work in physicians’ practices.

Starting the process

The anchor of the care coordination team is the nurse care manager, who will bring together the resources needed to drive the plan of care. These specially trained nurses follow up with patients discharged from the hospital or emergency department and answer questions about the plan of care and promoting adherence to it. They can often troubleshoot or triage many problems and make sure that urgent issues surface quickly to the provider.

“Our case managers reach out to patients to have a dialogue about their concerns and tailor our outreach to their schedule and communication preferences,” says Pamela Fisher, BSN, RN, a care coordination manager. “We use several data-driven tools to complement what we learn to develop an action plan may address medical management needs, potential gaps in care, barriers to care, health maintenance opportunities, behavioral health needs, social determinants of health, medication management, patient support systems, and health literacy.”

Care managers may also liaise with clinical resources in provider, practice, and insurance payer settings, often acting as an advocate. “Nurse care managers are a partner with the patient, their provider, and the patient’s health insurance plan to connect patients to services and resources for a variety of social needs,” says Cathryn Kelly, MSN, RN, RD, CCCTM, CMSRN, formerly a care coordination manager. “We use a patient-centric approach and techniques like motivational interviewing, to identify and focus on what personally matters to them. And, in doing so, we enable our patient to find ways to meet their provider’s plan of care goals for better health outcomes.”

An integrated EMR is also a key communication tool to keep all care team members informed of the as the patient’s needs and circumstances change. The care manager plays a centralized role to help patients be at their physical, functional, and emotional best while managing one or more medical circumstances. “We strive to personalize the care management experience to ensure the highest quality care is provided in an efficient and cost-effective way while putting the patient’s quality of life goals at the center,” says Kelly.

Medication management

Pharmacists also play an outsize role in care coordination. Medication reviews can identify duplicate medications or those no longer appropriate, improving safety and cutting out-of-pocket costs for patients. Simplified regimens can lead to better compliance and better outcomes for diabetes, hypertension, depression, and other chronic conditions. Reminders and pill packaging along with mail order can be part of the plan to get the right medication to the patient every time. Those practices that don’t have access to a pharmacist can turn to community pharmacists. One group found that its higher risk patients visited their pharmacy 35 times a year – far more often than the three times they saw their primary care provider. (3)

Local physician John Stoeckle, MD, CHQS, shared an example: “One patient with a deep venous thrombosis did not have insurance coverage. This is not a patient for which I would have felt comfortable prescribing warfarin due to reliability issues. Our care manager was able to work with him both on the process for getting insurance and in getting him affordable coverage for an anticoagulant.”

Meeting the needs of growing numbers of patients through distributed care in a personalized way means adopting population health with individualized care coordination. Whether physicians and health care providers access a virtual team or have key team members in the office, data driven care coordination will help deliver on the commitment to patients even as physicians feel that they are increasingly doing more with less.

Care coordination reaches across the continuum

A case study bridging the PCP with psychiatry and a clinical health coach

Ms. Smith is a 65-year-old grandmother with a 15-year history of Type 2 diabetes complicated by elevated blood pressure and recurrent episodes of major depression. Ms. Smith has a BMI of 38 and has struggled with her weight since childhood. At a doctor’s visit, she was found to have an HbA1c of 8.9%, a blood pressure of 148/88 and PHQ-9 score suggesting minor depression. Her primary care doctor (PCP) worked with the social workers in care coordination to refer Ms. Smith to a psychiatrist. In collaboration with her doctors, Ms. Smith was introduced to a clinical health coach and the entire care team stayed connected through care coordination’s electronic patient portal.

Ms. Smith missed the first appointment with her psychiatrist, which was picked up by the charting system. The clinical health coach called Ms. Smith to set up another appointment. During the subsequent first visit, the psychiatrist adjusted her depression medication, but also found that her blood pressure was elevated. Ms. Smith also complained of headache and fatigue, so care coordination alerted her PCP, who then adjusted her anti-hypertensive medications. Shortly after, the clinical coach followed up to make sure Ms. Smith knew how to take her medication and was taking it as directed. The clinical coach suggested Ms. Smith check her blood pressure every other day, which she did. Ms. Smith slowly began to feel less depressed, and her BP slowly reduced to target levels with one more medication adjustment.

How care coordination works: Adding another level

One case, summarized by Populytics Care Manager Pamela Youse, RN, illustrates the partnership between the provider, the patient, and their nurse care manager. The goal is to connect the patient with resources to self-manage their health conditions and be more adherent to their medical management.

“This patient, a middle-aged man with a history of uncontrolled Type 2 diabetes and who is completely blind, was referred to care coordination by his primary care provider. During the pandemic, he and his wife, who is also completely blind, moved from a distant state to live closer to their only living family member. The patient’s struggles to adapt to the climate change and navigate his new environment were made harder by other comorbid conditions.

Due to his blindness, the patient was afraid to use appliances to prepare healthy meals and relied on prepared and fast foods. As a result of these physical and dietary challenges, his HgbA1C continued to climb. He shared with the care manager that since he could not see or read the results on his glucometer,  he was not regularly tracking his blood sugar. With concern for his worsening situation, the patient’s PCP intervened to prescribe a glucometer that would provide a verbal reading, but there were insurance coverage barriers.

The nurse case manager and the PCP communicated daily and successfully set up a peer-to-peer review with the patient’s insurance to obtain equipment that will ‘talk’ to the patient. Since then, the patient is keeping logs of his blood sugars and continues working with care management to review his medications and insulin regimen with his doctor.”


1.Boersma, P, Black LI, Ward BW. Prevalence of Multiple Chronic Conditions Among US Adults, 2018. Prev. Chronic Dis 2020; 17:200130.

  1. Agency for Healthcare Research and Quality; Care Coordination
  2. Integrating Community Pharmacists into Complex Care Management Programs. presented by Trista Pfeiffenberger, 6/22/17 accessed at